CurrentAmeriHealth Caritas LouisianaPolicy CCP.4018

Lynch Syndrome Testing

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Coverage and prior authorization for Lynch syndrome genetic testing for AmeriHealth Caritas Louisiana Medicaid managed care members in Louisiana.

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyLynch Syndrome Testing

Policy CodePolicy CCP.4018

Change TypeReference updates only

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateMay 1, 2027

Key ActionObtain prior approval from AmeriHealth Caritas Louisiana before performing genetic testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Amsterdam II affected relatives

<50Amsterdam II age threshold

≥5%Predictive-model risk

RequiredPrior approval

Once/lifetimeTesting frequency

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CurrentAmeriHealth Caritas LouisianaPolicy CCP.4018

Lynch Syndrome Testing

Customize your policy alerts

Sign up for amerihealthcaritaslouisiana Policy CCP.4018 alerts

Get alerted when Policy CCP.4018 changes without checking for updates manually.

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Coverage and prior authorization for Lynch syndrome genetic testing for AmeriHealth Caritas Louisiana Medicaid managed care members in Louisiana.

Policy Summary

PayerAmeriHealth Caritas Louisiana

PolicyLynch Syndrome Testing

Policy CodePolicy CCP.4018

Change TypeReference updates only

Effective DateN/A

Last ReviewJan 1, 2026

Next Review DateMay 1, 2027

Key ActionObtain prior approval from AmeriHealth Caritas Louisiana before performing genetic testing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Amsterdam II affected relatives

<50Amsterdam II age threshold

≥5%Predictive-model risk

RequiredPrior approval

Once/lifetimeTesting frequency

Medical Necessity Criteria

Medical necessity criteria

Covered when at least one of the following medical-necessity pathways is met:

Lynch syndrome testing pathways

Amsterdam II criteria
- Amsterdam II family relationship and tumor requirements: One affected relative is a first-degree relative to the other two; two or more successive generations are affected; one or more affected individuals were diagnosed before age 50; familial adenomatous polyposis is excluded in colorectal cancer; and tumors are verified by pathological examination.At least 1 diagnosis before age 50; at least 2 successive affected generations
  All listed conditions are required.
Revised Bethesda Guidelines
- Bethesda criterion 1: Colorectal or uterine cancer was diagnosed in a member younger than 50 years.<50 years
- Bethesda criterion 2: The member has synchronous or metachronous colorectal cancer, or another Lynch syndrome-associated tumor.
- Bethesda criterion 3: The member has colorectal cancer with MSI-H histology diagnosed before age 60.<60 years
  MSI-H histology includes tumor-infiltrating lymphocytes, a Crohn's-like lymphocytic reaction, mucinous or signet-ring differentiation, or a medullary growth pattern.
- Bethesda criterion 4: The member has colorectal cancer and one or more first-degree relatives with a Lynch syndrome-related tumor, with one of the cancers diagnosed before age 50.At least 1 diagnosis before age 50
- Bethesda criterion 5: The member has colorectal cancer and two or more first- or second-degree relatives with Lynch syndrome-related tumors, regardless of age.At least 2 affected first- or second-degree relatives
Predictive-model risk: The member has an estimated Lynch syndrome risk of at least 5 percent based on MMRpro, PREMM5, or MMRpredict.≥5% estimated risk
These are the predictive models named in the policy.

Authorization and Denial Risk

Prior Authorization

Prior Authorization Required

Genetic testing for Lynch syndrome must be prior approved by AmeriHealth Caritas Louisiana before testing.

Submit the testing request for prior approval before the test is performed.

Denial Risk

Denial Risk: Criteria or Prior Approval Not Met

Coverage may be denied when the medical-necessity criteria are not met or when required prior approval has not been obtained. Testing is medically necessary only when the member meets Amsterdam II criteria, the Revised Bethesda Guidelines, or has an estimated risk of at least 5% based on MMRpro, PREMM5, or MMRpredict.

Confirm that at least one covered medical-necessity criterion is documented.
Obtain AmeriHealth Caritas Louisiana prior approval before testing.

Lynch Syndrome Background

Lynch syndrome is a hereditary cancer predisposition syndrome associated with colorectal, endometrial, small-bowel, ureteral, renal-pelvis, and other Lynch syndrome-related tumors. Coverage is evaluated within a clinical framework that considers family-history patterns, tumor characteristics, and validated predictive-model estimates of Lynch syndrome risk. Genetic testing is medically necessary when at least one recognized pathway is met: Amsterdam II criteria, a Revised Bethesda Guideline, or an estimated risk of ≥5% using MMRpro, PREMM5, or MMRpredict.

Key Definitions

MSI-H

TermMSI-H (microsatellite instability-high)

DefinitionChanges in two or more microsatellite-marker panels in the tumor.

Applicable panelsThe five microsatellite-marker panels recommended by the National Cancer Institute.

MSI-H histology

Tumor-infiltrating lymphocytesPresence of tumor-infiltrating lymphocytes.

Lymphocytic reactionA Crohn's-like lymphocytic reaction.

DifferentiationMucinous or signet-ring differentiation.

Genetic Testing for Lynch Syndrome

Genetic testing for Lynch syndrome

Genetic testing for Lynch syndrome is covered as medically necessary when the member meets at least one of the following pathways:

Covered Lynch syndrome testing indications

Amsterdam II criteria
- Required Amsterdam II features: One affected relative is a first-degree relative to the other two; two or more successive generations are affected; one or more affected individuals were diagnosed before age 50; familial adenomatous polyposis is excluded in colorectal cancer; and tumors are verified by pathological examination.At least 1 diagnosis before age 50; at least 2 successive generations
Revised Bethesda Guidelines
- Criterion 1: Colorectal or uterine cancer was diagnosed in a member younger than 50 years.

Testing Eligibility and Frequency

Under the Amsterdam II criteria, the family history must include at least three relatives with a Lynch syndrome-associated cancer, including colorectal, endometrial, small-bowel, ureteral, or renal-pelvis cancer. One affected relative must be a first-degree relative to the other two, two or more successive generations must be affected, and at least one affected individual must be diagnosed before age 50. For colorectal cancer, familial adenomatous polyposis should be excluded, and the tumors must be verified by pathological examination.

Testing for a particular disease should generally be performed once per lifetime. Repeat testing may be considered only in rare circumstances, such as when the previous testing methodology was inaccurate or when a new discovery has added significant mutations relevant to the disease.